integrated managed care clinical symposium north central · 2020. 8. 5. · 1 october 2017....

1 October 2017

Integrated Managed Care Clinical Symposium –

North Central(Chelan, Douglas, Grant counties)

Co-Hosted by:

Agenda

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• Coordinated Care Overview• Beacon Overview• IMC Overview• Case Management Overview• Common PA Standards• How to work with each MCO• Questions and Answers

Coordinated Care of WA Mission Statement: To be the highest quality health plan in Washington, and the health plan of choice for members and providers.

• Serving over 250,000Washingtonians

• Coverage includes Medicaid,Foster Care, Health BenefitExchange

• 360 Employees statewide with officesin Seattle, Wenatchee, Tacoma &Yakima

• NCQA Accreditation accredited asCOMMENDABLE

Embedded Care Management and

Member Connections staff in the

community, including community health centers, hospitals,

jails, and other pilot sites

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Coordinated Care Statewide Coverage

Pacific

Whatcom

Clallam

Jefferson

Skagit

Snohomish

Chelan Douglas

Grant

Okanogan

Adams

Lincoln Spokane

Ferry Stevens

Pend Oreille

Yakima Benton

Franklin

Walla Walla Columbia

Whitman

Garfield

Asotin

Kittitas Pierce

Grays Harbor

Mason

Kitsap King

Thurston

Lewis

Cowlitz

Clark

Skamania

Klickitat

Washington Apple Health

Apple Health Core Connections (Foster

Care)



Care)

Washington Apple Health Apple Health Core

Connections (Foster Care)



Care)



Care)



Care)


Apple Health Core Connections (Foster Care)





Care)



Care)


Apple Health Core


Apple Health Core Connections

(Foster Care)

Apple Health Core


Apple Health Core



Apple Health Core



Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care)

Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core


Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections

(Foster Care) Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care) Washington Apple Health,

Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care)

Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care)Washington Apple

Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care)




Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster

Care)

Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster

Care)Washington Apple Health, Ambetter from Coordinated Care, Apple Health Core Connections (Foster Care)


Washington Apple Health, Ambetter from Coordinated Care, Allwell from Coordinated Care, Apple Health Core Connections (Foster Care)

Washington Apple Health, Ambetter from Coordinated Care, Allwell from Coordinated Care, Apple Health Core




4



Care)


Apple Health Core


Beacon is Committed to Strong Partnership with Washington State

Strong Medicaid and Non-Medicaid Experience

Implemented the first BH-ASO in partnership in Clark andSkamania Counties in ~90 days

Manage the crisis system access and coordinationcontracts with the IMC MCOs, county governments, keyproviders and other community stakeholders

Dedicated Local Team

• BH-ASO staff in Vancouver, Washington

• Expansion plans to hire in North Central

Military, Commercial, Employer Experience

• Military contract served out of Bellingham, Washington

• Boeing MHSUD and EAP contract

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Shared Mission and Vision

Our mission is to help people live their lives to the fullest potential. Our vision focuses on improving the health and well-being of individuals coping with mental health and substance use conditions.

Healthier Washington will help people experience better health throughout their lives and receive better—and more affordable—care when they need it.

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The BH-ASO Will Provide a Series of Services that Supplement Those Provided by the Managed Care Plan

Maintain and Administer Crisis Services

• Maintain 24/7/365regional crisis hotline

• Provide mental healthcrisis services, includingmobile outreach team

• Administer InvoluntaryTreatment Act

• Administer ChemicalDependency InvoluntaryCommitment Act

Manage SUD and MH braided Funding Benefits

• Proviso funds

• Federal Block Grant(MHBG & SABG)

• Criminal JusticeTreatment Account

• Dedicated MarijuanaAccount

• Jail Transition Services

• State General Funds

Admin support, financial support and miscellaneous

• Behavioral HealthOmbudsman

• FYSPRT & CLIP

• State hospital liaison andPeer Bridger

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IMC Overview

Physical Heath

Substance Use

Disorder

Mental Health

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North Central IMC Go-Live

January 1, 2018

Chelan County

Douglas County

Grant County

NOTE: Medicaid members in surrounding counties will remain Apple Health with Apple Health benefits.

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Limited Coordination

Current State: Fragmented Financing and Care

Mental Health & Chemical Dependency

Mental Health & Chemical Dependency

Care Delivery

$

$

$

$

FinancingLim

ited Coordination

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Physical Health Physical Health

Integrated Services

Physical HealthMental Health

Chemical Dependency

$

Care DeliveryFinancing

Future State:Integrated Financing = Integrated Care

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Physical Health

Mental Health

Chemical Dependency

Two HCA Contracts Cover All Enrollees

MedicaidCoveredServices

• Physical Health (e.g. Apple Health)• Mental Health (MH)• Substance Use Disorder (SUD)

• NOTE: MH and SUD = Behavioral Health (BH)

WrapAroundBenefits

• Behavioral Health services NOT covered or funded by Medicaid• These services are funded by General Fund – State dollars• Examples of services:

• eg. room & board, sobering services

Enrollees

• Apple Health Medicaid children, families, adults, blind/disabled• Behavioral Health Services Only (BHSO) members will only receive behavioral health

benefits through MCOs. Medical benefits remain Fee-For-Service

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What Does Better Look Like?

Better medical care and

outcomes for people living with chronic

mental illness

Better identification

and treatment of behavioral

health conditions in primary care

Better integration of fragmented

system through care

coordination –no falling

through cracks

Triple Aim

Better health

outcomes

Lower total cost of care

Better Patient/ Provider

experience

Better inclusion of

Social Determinants

of Health

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Provider Network

• Integrated Delivery Systems (Confluence)• Primary Care Clinics (i.e. Columbia Valley Community Health, Moses Lake CHC, Columbia Basin

Health Association)

Primary Care

• State Hospitals--MCOs do not administer this benefit• Inpatient Psychiatric Hospitals• Community Mental Health Agencies• Behavioral Health Providers-Group Practices• Individual Behavioral Health Providers

Mental Health

• Substance Use Disorder (SUD)/ Chemical Dependency Agencies• Inpatient and Outpatient Treatment

Substance Use

• Beacon Health- provides crisis service response 24 hours a day/7 days a week/365 days a yearand administers non-Medicaid services to non-Medicaid members

Behavioral Health Administrative Services Organization (BH-ASO)

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Continuum of Integrated Clinical SerivcesContinuum of Integrated Clinical SerivcesContinuum of Integrated Clinical SerivcesContinuum of Integrated Clinical SerivcesContinuum of Integrated Clinical SerivcesContinuum of Integrated Clinical Serivces

Individual ClientIndividual ClientIndividual ClientIndividual ClientIndividual ClientIndividual Client

Required sub-contract






HCA Contract with BH-ASOHCA Contract with BH-ASOHCA Contract with BH-ASO

Individual ClientIndividual ClientIndividual Client

Continuum of Integrated Clinical SerivcesContinuum of Integrated Clinical SerivcesContinuum of Integrated Clinical Serivces

Fully Integrated MCO

Fully Integrated MCO

Fully Integrated MCOBH-ASOBH-ASOBH-ASOBH-ASO

HCAHCAHCAHCAHCA

Fully Integrated

MCO

Fully Integrated

MCO

Fully Integrated

MCO

HCA

Role of the Behavioral Health ASO

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Case Management Overview

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•

•

•

•

•

•

•

•

Care Coordination with Integrated Managed Care (IMC)

• Community Based Care Coordination (basics plus BHcollaboration)– Working with PCP and BH providers to coordinate and

collaborate– Local providers know the patient best– Allied Service Coordination (Community partners)

• Coordination of BH Services by MCO– SUD– State Facilities– Outpatient Wrap Around Care– Justice System– BH-ASO Crisis Services

Physical Heath

Substance Use

Disorder

Mental Health

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Initial Health Screening:

Newly enrolled members receive an Initial Health

Screening within the first 60 days of enrollment

However, many members are difficult to contact

Based on screening results and other utilization data, members are referred to

Care Management for further assessment

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Examples for CM referrals include:

High utilizer of careDifficulty managing a chronic conditionPsychosocial needs impacting managementAssistance navigating health plan systemGaps in care

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Care Management Process

Comprehensive Health Risk Assessment

Specialized Assessments, including

disease specific, depression, and quality

of life

Goal Setting in collaboration with the

member

Motivational interviewing techniques

to encourage the member toward improved health

outcomes

Removal of barriers to care and services

including navigating the health plan system

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Care Management LevelsCare Management services are designed to support the overall Wellness of enrollees with a focus on improving health outcomes.

MCO’s offer two levels of Care Management Services:

Care Coordination Services (CCS) Focus on short-term or intermittent needs, such as: Access to care/services addressing social needs Improving clinical outcomes Increasing self-management skills

Complex Case Management (CCM) Focus on individuals with chronic or complex needs requiring ongoing care management.

Services include:

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Person-centered approach to care plan development Utilization of evidence-based practices in screening and intervention Addressing gaps in care Coordination of care across the continuum Designed to meet NCQA Complex Case Management standards

Advance DirectivesMCOs are required to educate and inform employees, providers, and members about a patient’s rights to an Advance Directive.

An Advance Directive gives written instructions about a patient’s medical care in the event that the patient is unable to express his or her medical wishes.

For the State of Washington there are three types of Advance Directives:

• Health Care Directive/Living Will - specifies anindividual’s wishes about end of life care.

• Durable Power of Attorney - names another personto consent to, stop, or refuse treatment if anindividual is incapable of doing so.

• Mental Health (MH) Advance Directive – allows aperson with capacity to state mental healthtreatment preferences in a legal document that willgovern during periods of incapacity (see sectionbelow for more information on MH AdvanceDirective).

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what does

mean to you?

ofLIFEQUALITY

Advance DirectivesTo be valid, a Mental Health Advance Directive must:

• be in writing;

• include language indicating a clear intent to create adirective;

• be dated and signed by the patient, or be dated and signedin the patient’s presence at his or her direction;

• state whether the directive may or may not be revokedduring a period of incapacity;

• be witnessed in writing by at least two adult witnesses; and

• conform substantially to the statutory format.

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Common Access to Care Standards

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Access StandardsAll MCO’s access standards comply with the Healthcare Care Authority (HCA) and the National Committee for Quality Assurance (NCQA) requirements. According to our contracts with HCA and our commitment towards quality improvement, providers must also adhere to these standards.

Type of Care Appointment Wait Time

Preventive Care Appointment Within 30 calendar days of requestSecond Opinions Within 30 calendar days of requestRoutine Primary Care Within 10 calendar days of requestUrgent Care Within 24 hoursEmergency Care 24 hours/7 daysAfter-Hours Care Available by phone 24 hours/seven daysOffice Waiting Time Should not exceed 30 minutesCare Transitions – PCP Visit Within 7 calendar days of discharge from inpatient or

institutional care for physical or behavioral health disorders or discharge from a substance use disorder treatment program

Care Transitions – Home Care If applicable, Transitional health care by a home care nurse or home care registered counselor within 7 calendar days of discharge from a substance use disorder treatment program, if ordered by the enrollee’s primary care provider or as part of the discharge plan

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Behavioral Health Standards

All MCO’s access standards comply with the Healthcare Care Authority (HCA) and the NationalCommittee for Quality Assurance (NCQA) requirements. According to our contracts with HCAand our commitment towards quality improvement, MCO network of Behavioral healthproviders must adhere to these standards.

Behavioral Health Appointment Types Standard

Life threatening ImmediatelyNon-life threatening Within 6 hoursUrgent care Within 24 hours Routine care Within 10 calendar days

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GUIDE

LINES

REGULATIONS

Shared Utilization Management Regulations

• FIMC/WrapAround Contracts

• WACs and RCWs

• HCA Provider Guide

• HCA Health Technology Assessment Committee

• NCQA Standards

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ANCEPLI ECOM

Disorder

AppliedSocial

PsychoanalysisTestingOutpatient

Partial

Psych

PACT

Behavioral

Family

Treatment

Therapist

Therapy

Neuropsych

substance

Medical Necessity

Washington State law defines medical necessity as:

• A requested service that is intended to prevent,diagnose, correct, cure, alleviate or preventworsening of conditions in the client that• endanger life,• cause suffering or pain, or• result in an illness or infirmity or threaten to cause

or aggravate a handicap, or cause physicaldeformity or malfunction AND

• There is no other equally effective, moreconservative or substantially less costly course oftreatment available or suitable for the clientrequesting the service.

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Program

Counselor

Psychologist

CBT Psychiatrist

Residential

Worker ECT

Day

Hospitalization

Intensive Analysis

WIse

Use

•

•

NCQA Accreditation

• All MCOs are required to be accredited by theNational Committee for Quality Assurance(NCQA)

• An independent, not-for-profit organization whohas developed quality standards for healthplans.–Accredited health plans today face a rigorous set of

more than 60 standards and must report on theirperformance in more than 40 areas in order toearn NCQA’s seal of approval

–Includes 14 UM specific standards

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http://www.ncqa.org/Programs/Accreditation/Health-Plan-HP

UMUM

Utilization Management

• NCQA Definition of Utilization management:Evaluating & determining coverage for andappropriateness of medical & behavioral healthcare services, as well as providing neededassistance to providers and patients, incooperation with other parties, to ensureappropriate use of resources.

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REVIEW

Types of UM Reviews

• Pre-Service/Prior AuthorizationServices in which authorization must be obtained prior to start of service

• ConcurrentServices in which authorization is obtained during a course of care and prior to the end of the episode of care.

• Retrospective/Post-ServiceA review conducted after the service has occurred to determine if the services were medically necessary

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http://ajslp.pubs.asha.org/article.aspx?articleid=2204333

Emergent Services

• PsychiatricA mental health condition in which the patient is a danger to themself, others or is gravely disabled.

• MedicalA medical condition that a prudent lay person might anticipateserious impairment to his or her health in an emergencysituation

The American College of Emergency Physicians has long believed that anyone who seeks emergency care suffering from symptoms that appear to be an emergency, such as chest pain, should not be denied coverage if the final diagnosis does not turn out to be an emergency.

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https://www.pinterest.com/explore/psychology-tattoo/

http://www.clipartbest.com/blue-medical-symbol

http://www.clipartbest.com/blue-medical-symbol

MCO Specific UM Guidelines

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Different MCO’s, similar UM processesWhat’s the same?

Types of review:Pre-Service/Prior AuthorizationConcurrentRetrospective/Post-Service

Standards:Use of standardized, nationally recognized, evidence-based criteria sets to make determinations of “medical necessity” which is common language.

What may be slightly different?

The method of authorization: Phone/fax/online submissionsThe forms that you may see for each MCO may have some slight variation. The specific services that may require authorization – the variance will be very minor.

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Plan Referrals and Prior Authorizations for

Coordinated Care

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Utilization Management (UM) Processes

Prior Authorization

Concurrent Review

Discharge Planning

Psychotropic Medication Utilization

Review

Care Management

Provider & Member Outreach

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UM Tools

Prior Authorization

Tool Benefit Grid PA Forms

HCA Provider Guides Fee Schedules Provider

Manual

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Prior Authorization (PA)

• Authorization can be requested using afaxed form, provider web portal, or forurgent services/admissions by phone

• Fax forms• Web Portal• Phone

• (844)208-8885• All emergent behavioral health admission

notifications and reviews are conductedtelephonically

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https://www.coordinatedcarehealth.com/providers/resources/forms-resources.html

https://provider.coordinatedcarehealth.com/sso/login?service=https://provider.coordinatedcarehealth.com/careconnect/j_spring_cas_security_check

Prior Authorization

• Providers can check our authorization requirementsby using our online PA code look up tool

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https://www.coordinatedcarehealth.com/providers/preauth-check/medicaid-pre-auth.html

Prior Authorization

• Services requiring prior authorization:• Planned admissions• Psychological Testing (above 2 units, or

above 7 units for ABA Centers of Excellence)• ECT• Transcranial Magnetic Stimulation• WISe/PACT- requires notification for

program entry and authorization forcontinuation in program

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UM Discharge Planning

MemberNeeds Assessment

to Developing an

Integrated Discharge Plan

Medical needsResources/

Appointments

House Resources Long/short term

medical care, Long term /short mental

health

Mental Health Resources

Needs

Chemical Dependence

Needs

Financial Needs-Example is SSI

Transportation needs

Basic Needs met:Communication

Food

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Psychotropic Medication Review

• Review of psychotropic medication use for pediatricmembers

• Identify members who may be at risk for harm due touse outside of clinical parameters or higher thanrecommended doses

• Behavioral Health Medical Director sendscommunication to provider about prescribing, optionsfor consultation, and performs follow up

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Customer Service• Call one number for all your needs: (877) 644-4613

• Our hours are 8 am-5 pm, Monday-Friday• Our staff are located in Tacoma and Seattle

Average experience for last 12 months:

12 second ASA

0.85%abandonment

Average experience for last 12 months:

95% Quality Score

• Real-time call volume monitoring tomanage staffing levels to ensure lessthan 3% abandonment and 30second average speed to answer.

• Evaluate monthly statistics to ensureright-sizing of staffing levels overall.

• Quality Audits are conducted forevery agent to ensure at least 94%call quality rates.

• Monthly, quarter, and annual qualitymetrics are evaluated for potentialtraining or process improvement.

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North CentralWashington BH-ASO

October 2017

Yes

Yes

No

No

No

No

No

No

No

No

No

Registration Complete?

Complete Registration

Sent to Clinical Care Mgr. (CCM) for review

All required

info provided?

CCM requests additional info

CCM determines whether treatment meets criteria

for medical necessity

Criteria met?

Service denied

CCM authorizes levels of care and treatment services that are

specified as covered services

Provider submits authorization request via ProviderConnect




All required

info provided?




Criteria met?

Service denied







All required

info provided?




Criteria met?

Service denied







All required

info provided?




Criteria met?

Service denied




Request for Non-Crisis Services –Authorization Review Process


No



All required

info provided?

No




Criteria met?

Service denied

No



• Authorizations are granted for thefund(s) for which the individual iseligible

• Authorizations are for a specific numberof services/units of services/days andfor a specific time period based on theindividuals clinical needs


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CCM Review Criteria

Beacon clinicians are trained to match the needs of the individual to appropriateservices, levels of care, treatment and length of stay, and community supports.

Beacon clinicians obtain clinical data from the provider and evaluates thisinformation and references applicable clinical criteria to determine medicalnecessity of the requested level of care

Providers should be prepared to provide the following information at the time ofthe review:

Demographics Estimated length ofStay

Previous Treatment history

Diagnosis (inclusiveof behavioral andmedical)

Reason for Admission TreatmentGoals/Treatment Plan

Specific plannedinterventions

Precautions forspecific risk behaviors

Family Involvement

Barriers to discharge Discharge Plan Aftercare required upondischarge

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Clinical Criteria & Level of Care Determination

To determine the appropriate level of care during a review the CCM evaluate the pertinent clinical information relative to the level of care criteria:• Medical Necessity/Level of Care Criteria can be found at:

http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm

• Additional Washington State ASO Clinical Criteria posted on thewebsitehttp://wa.beaconhealthoptions.com/providers/providers_manual.html

• Substance use criteria are based on ASAM PPC-2 criteria publishedby the American Society for Addiction Medicine (ASAM)

• To order a copy of the ASAM criteria, please go to the followingwebsite:

• www.asam.org/PatientPlacementCriteria.html

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https://www.beaconhealthoptions.com/providers/beacon/handbook/clinical-criteria/

http://wa.beaconhealthoptions.com/providers/providers_manual.html

https://www.asam.org/resources/the-asam-criteria

Determination Review Definitions

• Initial Review – Refers to the first review ofservice

• Concurrent Review – All reviews after theinitial review

• Appeal Review – Request for a secondreview following a denial of service

• Retrospective Review – Review requestafter an individual is no longer in treatmentfor that service

• In cases where retrospective review is notavailable under the guidelines, the providerwill be informed of this status

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Reviews

Determination Timeframes for Initial Review

Level of Care Standard

Inpatient, CSU 12 hours

Residential 24 hours for MH, 72 hours for SUD

IOP, Day Supports Fifteen (15) calendar days

Outpatient inclusive of Psychological Testing, Clubhouse, Respite Care

Fifteen (15) calendar days

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Determination Timeframes for Concurrent Review


Inpatient, CSU 24 hours

Residential24 hours for MH, 72 hours for SUD

IOP, Day Supports Fifteen (15) calendar days

Outpatient inclusive of Psychological Testing, Clubhouse, Respite Care

Fifteen (15) calendar days

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CCM Discharge Review Criteria

The following information may be requested and must be documented:

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Aftercare appointment• Date of appointment• Time of appointment• Name of specific

provider individual isto see

• Where the individualis to go for aftercareappointment

Individual’s contact information • Phone number and

address of whereindividual is beingdischarging

• Emergency contactinformation (family,support, socialsupport available)

Clinical information • Date of Discharge• Diagnosis at

Discharge• Medications with

dosages• Community

resources referred

Determination Timeframes for Appeal Review


Inpatient, CSU

Within three (3) calendar days of the receipt of the request for review Notification: written notice to the provider and the individual within the decision timeframe

Residential, IOP, Day Supports

Within fourteen (14) calendar days of receipt of the request.Notification: Verbal notice to provider and the individual within the decision timeframe. written notice to the individual and provider within 72 hours of the verbal notification

Outpatient inclusive of Psychological Testing, WISE, PACT, Clubhouse, IOP, Day Supports, Respite Care

Within fourteen (14) calendar days of receipt of the request.Notification: Verbal notice to provider and the individual within the decision timeframe. written notice to the individual and provider within 72 hours of the verbal notification

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Communicating with Beacon Health Options

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Communicating with Beacon HealthOptions

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Contact Information

Customer Service: General questions regarding referrals, claims,complaints and grievances

855.228.6502 – Monday through Friday, 8 a.m.-5 p.m. PT National Provider Service Line: General questions regarding

credentialing and contracting800.397.1630 – Monday through Friday, 8 a.m.-5 p.m. PTEmail – Beacon [email protected]

EDI Help Desk: ProviderConnect questions, including registrationand direct or batch claims submission

888.247.9311– Monday through Friday, 11a.m.-3 p.m. ETClaims Mailing Address:

PO Box 1850Hicksville, NY 11802-1850

5454

mailto:[email protected]

Additional Resources for the North Central Washington BH-ASO

Beacon’s website : www.wa.beaconhealthoptions.com

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Home About Your Rights & Responsibilities Contact In a Crisis

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http://wa.beaconhealthoptions.com/

integrated managed care clinical symposium north central · 2020. 8. 5. · 1 october 2017....

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